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Tuesday, July 31, 2012

There is something surreal about the current debates that are taking place in some European countries about male circumcision. Well, it is not so much male circumcision as such, but the circumcision of very young Jewish and Muslim boys in Germany and the Netherlands. In Germany a court has recently declared circumcision on non-medical grounds illegal – much like female genital mutilation is illegal in the country. The court’s rationale was, essentially, that male circumcision for religious or cultural purposes is akin to assault or battery. If there is no overriding clinical benefit to the child undergoing the surgery, it is not justifiable to proceed with it.

In the Netherlands the Royal Dutch Medical Association has recently come forward arguing that male circumcision should be discouraged. The association notes in a report that a large number of complications resulting from circumcision are known, including ‘infections, bleeding, sepsis, necrosis, fibrosis of the skin, urinary tract infections, meningitis, herpes infections, meatisis, meatal stenosis, necrosis and necrotising complications, all of which have led to the complete amputation of the penis.’ Even deaths have been reported. There is also some evidence that circumcision diminishes pleasure during sexual intercourse and generally has a negative impact on the enjoyment of sex. The results of a large cross-sectional study in Denmark, published in 2011, reveal that ‘circumcision was associated with frequent orgasm difficulties in Danish men and with a range of frequent sexual difficulties in women, notably orgasm difficulties, dyspareunia and a sense of incomplete sexual needs fulfilment.’ It appears to be the case that that male circumcision is not a cost neutral, risk-free activity.

On the other side of the equation is what the World Health Organisation describes as ‘compelling evidence’ that circumcision reduces the HIV infection risk of adult males to a significant extent. This has led some to suggest population level circumcision of males in sub-Saharan African countries. A public health argument might plausibly be made for such a policy in areas with high HIV prevalence. However, neither Germany nor the Netherlands are located in sub-Saharan Africa. The prevalence of HIV/AIDS is thankfully quite low in those countries, and there is no reason to suggest that this is going to change any time soon.

Male as well as female genital mutilation are predominantly religiously or culturally motivated practices. Remarkably, the two world religions that tend to be so often at loggerheads, namely Islam and Judaism, both fervently support male mutilation while supporters of female genital mutilation will only be able to find support among Islamic scholars. I am not an expert in world religions and I have little doubt that theological arguments over what Judaism’s and Islam’s holy documents prescribe are likely possible, even among well-intentioned experts. Leaving theological arguments aside, however, there is a strong cultural consensus in Jewish and Muslim communities that male circumcision is something good.

Both in Germany and in the Netherlands representatives of the Islamic and Jewish faiths respectively charged those arguing against male circumcision with unfair discrimination. Indeed, one Rabbi reportedly went on the record claiming that the German court’s decision was ‘perhaps the most serious attack on Jewish life in Europe since the Holocaust.’ As has been noted by bioethics scholars quite a few times, we should be very suspicious if the holocaust argument is deployed in support or against something. Quite likely there is no reasonable argument to be had, hence the Nazi argument is wheeled in in order to discredit whatever it is that someone has a bone to pick with.

Of course, it is always possible that the motives of some of those arguing against circumcision are driven by ulterior intentions. You would have reason, for instance, to be suspicious if a Christian intelligent design organization hired an ex-Muslim atheist to campaign against Islam. However, it is surprising that it did not occur to these religious lobbyists that child welfare and fundamentally the child’s right to her bodily integrity are of paramount importance. In liberal Western democracies they rightly trump parental religious beliefs. The only issue that should matter in these debates is the affected children’s welfare. Religion or other cultural convictions, no matter how strongly felt, should not even enter into the equation. We do not permit Jehovah’s witnesses to prevent their off-spring from receiving blood transfusions when this is medically indicated. Why not? Simply put: we apply a child’s best interest standard. Best interest, when considered in a medical context, by necessity refers to health related concerns. It’s a legal standard applied, for instance in Canada. There is no good reason to deviate from this standard to accommodate the religious traditions of Muslims or Jews. It is also worth noting that we usually give parents significant room to make parental decisions on behalf of their children, precisely because we believe that they usually know what is in their children’s best interest. That might even explain why the paternalism-in-medicine doctrine has its roots in the idea of a good parent (well, father) doing what is in his child’s best interest, even if the child disagrees. In the case under consideration, however, it is clear that the motives driving the parents derive their strength from religious or cultural convictions rather than from empirical evidence in support of the need for a surgical intervention in every male child.

Surprisingly, in Germany major political parties from the centre right Christian Democrats to the Liberals as well as the leftish German Labour Party fell over one another promising to introduce legislation aimed at safeguarding purported parental rights to mutilate their children’s genitals for religious reasons. The Greens were expressly more concerned about ‘religious freedom’ than about child welfare. The parliamentarians expressed worries that otherwise Muslim and Jews just could not live any longer in Germany. Strangely the same concern does not seem to apply to Jehovah’s Witnesses who are forced to adapt their religious practices to German law protecting children against parental abuse. The parliament passed a resolution asking the government to create legislation aimed at permitting male circumcision as long as it occurs without ‘unnecessary pain’. The German foreign minister reportedly thought the parliament’s vote demonstrated that Germany is a cosmopolitan and tolerant society, when arguably it demonstrated that the country’s politicians are readily prepared to subjugate child welfare concerns to concerns about alleged religious freedoms. Interestingly enough, the same parliamentarians had no problems protecting women against female genital mutilation with an argument suggesting that it is ‘sittenwidrig’, ie against German customs or morals. This, of course, is question begging. How is female genital mutilation any more sittenwidrig than male genital mutilation? In a historical sense it is arguably against German customs as there is no such tradition in Germany, but history cannot as such provide normative guidance. Female genital mutilation clearly causes more harmful consequences, but these cuts might possibly also be undertaken without causing unnecessary (sic!) pain, and that seems to be the odd yardstick against which male circumcision is held. One cannot help but wonder, what other bodily parts the German parliamentarians might in the future see fit to be removed lawfully as long as the removal does not cause unnecessary (sic!) pain and as long as some religious ritual or other is attached to it.

Germany as well as other countries would be well advised to reconsider permitting religiously or otherwise culturally motivated irreversible surgical body modifications of children that serve no uncontroversial medically beneficial purpose. If a competent adult or a mature minor wanted to go ahead with circumcision, a case could easily be made to respect such wishes. However, in the case of children the child’s –medically understood - welfare should take precedence over parents’ religious convictions. That is how most societies rightly address this problem with respect to Jehovah’s Witnesses’ prohibition of blood transfusions and that is how we should handle it with regard to genital mutilations of the various kinds that are popular among particular religions. Parenthood should not be confused with unrestricted ownership, neither by parents nor by parliamentarians trying to accommodate religious convictions. It is surprising that using children as mere means to satisfy parental religious or cultural needs should be considered acceptable in the 21st century version of Immanuel Kant’s homeland.

Tuesday, July 17, 2012

So the US FDA has finally approved Truvada as an HIV Pre-Exposure Prophylactic (or PrEp if you fancy acronyms). I am not sure what to make of this, to be honest. The proposition here is to prescribe a chemotherapeutic to perfectly healthy people so they can protect themselves against HIV, at a cost of 13900 US$ per annum. What other protections are available? Use condoms. If you've sex with someone who's HIV positive and you want to have unsafe sex, make sure they're on HAART. If they are, the additional protection daily chemotherapy would offer to perfectly health people is close to non-existent and certainly not worth the cost paid. If you live in a society with high HIV prevalence, the odds are that it's a developing country. Your healthcare system should likely not even consider paying for such a prevention strategy, it's simply not cost effective, considering competing health needs in your society.

The drug was tested mostly on folks in high-risk groups who engage in somewhat unusual high-risk behaviour such as having plenty of unprotected sex with folks they do not know or folks they know to be HIV infected (the press release says nothing about the question of whether the latter group included folks who were known by their risk-taking participants to be on HAART), sex workers, etc. So, if you happen to belong to a group of people who engage in high-risk sexual behavior, you likely are disciplined enough to take daily chemotherapeutic drugs to compensate for your risk-taking. Really? This explains probably a 42% efficacy when compared to the placebo control. Adherence might have been a bit of an issue there... That might also explain why the FDA requires Gilead to keep track of everyone who's (supposedly ) taking Truvada and gets infected anyway. Drug resistance seems a serious concern. Little seems to be known about pregnancy and Truvada, so that's being tested while the drug is being marketed. - Who knows, there might be a market in this high-risk segment of the population, even though it seems unreasonable to me that someone who enjoys such thrills should go on chemotherapy while healthy. Might they might not better wait until they're infected? Equally, in societies where the prevalence of HIV is very high (say, Sub-Saharan Africa), is the proposition to hook large numbers of perfectly health people on these heavy hitting drugs, 'just in case'?

As I said, I'm not sure what to make of this, but I am surprised about the logic of prescribing chemotherapy to healthy individuals as a 'just in case' strategy. Good for the shareholders of Gilead, the maker of Truvada though. You're making money off 'treating' the healthy... To be fair, it is anything but unusual that healthy people are being subjected to treatment in prevention efforts. Just think of flu vaccines, Hep B vaccination and so on and so forth. However, in the case under consideration the proposition is lifelong chemotherapy. That has quite a different ring and quality to it. We should take our time to discuss the pro's and con's of such a prevention strategy carefully, instead of diving headlong into it.

Friday, July 13, 2012

I am sick and tired of the animal abuse that continues to take place during the Calgary Stampede. The third year running horses, forced to participate in Stampede events, got killed in accidents. This time the accident was taped. Suffice it to say that it is truly gruesome, not at all surprising, and that one can only hope that whatever weak animal protection laws Canada has in place are sufficient to bankrupt those responsible for running this idiotic event. One of the horse owners was displayed on TV, crying, describing the shock at the loss of his horses and calling them akin to being family members. He said, 'They're just like humans, they're our family. It's just devastating for our whole family. It's hard to take.' Quick question to you Sir: Would you also subject your other family members to participation in events where deadly accidents are an annual occurrence? If you do, perhaps you might want to seek professional help somewhere, because clearly you are terribly irresponsible with regard to your interactions with your family members.

A word, perhaps, to spectators in Calgary: Give that deadly accidents are an annual occurrence during the Stampede, it stands to reason that you're attracted to blood sports resulting in the gruesome deaths of sentient non-human animals. If you're into that sort of thing, why not attend sporting events where humans volunteer in risk-taking, as opposed to events where animals are being forced into risking their lives for your entertainment needs?

There is no excuse whatsoever for continuing this 'tradition' with its ever increasing death toll!